Nursing Elites

1. A client is being taught how to use crutches by a nurse. Which of the following instructions should the nurse include?

• A. Place weight on the underarms.
• B. Keep the elbows extended when walking.
• C. Support your weight on your hands.
• D. Hold the crutches 10 cm in front of you when standing.

Correct answer: C

Rationale: The correct answer is C: 'Support your weight on your hands.' When using crutches, it is important to support your weight on your hands rather than underarms to prevent injury to the axillary nerves and blood vessels. Placing weight on the underarms can lead to nerve damage and circulatory issues. Choices A, B, and D are incorrect. Keeping the elbows extended when walking is important for stability, holding the crutches slightly in front of you allows for proper balance, and supporting weight on the hands maintains the correct weight-bearing position.

2. A healthcare professional is preparing to administer a hepatitis B vaccine. Which of the following should the healthcare professional verify?

• A. Client's allergy to eggs
• B. Client's vaccination history
• C. Client's weight
• D. Client's blood pressure

Correct answer: B

Rationale: The correct answer is B: Client's vaccination history. Before administering the hepatitis B vaccine, it is essential to verify the client's vaccination history to ensure they are due for the vaccine. This helps in preventing unnecessary vaccinations and ensures the appropriate timing and dosage. Option A, the client's allergy to eggs, is not directly related to administering the hepatitis B vaccine. Option C, the client's weight, and option D, the client's blood pressure, are not factors that need to be specifically verified before administering the hepatitis B vaccine.

3. A client has been prescribed trazodone. Which of the following should be monitored?

• A. Blood glucose levels
• B. Liver function
• C. Mood changes
• D. Heart rate

Correct answer: C

Rationale: Correct. Trazodone is an antidepressant that can impact mood and behavior. Monitoring for changes in mood or behavior is crucial to assess the effectiveness and potential side effects of the medication. Monitoring blood glucose levels is not typically associated with trazodone use. While trazodone can affect liver function in some cases, monitoring liver function is not the primary concern compared to assessing mood changes. Trazodone can cause changes in heart rate in some patients, but the priority monitoring in this case should be related to its effects on mood.

4. A nurse is caring for a client who is in active labor. The nurse notes early decelerations in the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?

• A. Fetal hypoxemia
• B. Cord compression
• C. Uteroplacental insufficiency
• D. Head compression

Correct answer: D

Rationale: Early decelerations are caused by head compression during contractions, which is a normal response as the fetal head is being compressed during uterine contractions. This usually indicates that the fetus is descending into the birth canal. Choices A, B, and C are incorrect. Fetal hypoxemia, cord compression, and uteroplacental insufficiency typically present with variable or late decelerations on the fetal heart rate tracing, not early decelerations.

5. A nurse is assessing a client who is 24 hours postpartum. Which of the following findings should the nurse report to the healthcare provider?

• A. Uterine fundus is firm and midline
• B. Client's perineal pad is saturated in 15 minutes
• C. Client reports breast tenderness when breastfeeding
• D. Client's temperature is 100.4°F

Correct answer: B

Rationale: A perineal pad saturated in 15 minutes is a sign of excessive postpartum bleeding, which requires immediate medical attention to prevent postpartum hemorrhage. The other findings are normal postpartum occurrences. A firm and midline uterine fundus indicates proper involution, breast tenderness during breastfeeding is common due to engorgement, and a temperature of 100.4°F is considered within the normal range for the postpartum period.

Similar Questions